HomeMy Public PortalAbout5674-5676 SULTANA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEINER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, C17UNTY ENGINEER BUILDING
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FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS " -- - -- CROSS ST. C,
LOCALITY DISTRICT NO. USERIAL NO. (P RMIT NO.
-NEAREST — — -------------
CROSS ST. iJ
— — 94
REC �1VE�D/B�Y Ready for Inspection DATE ISS ED
OWNER ' r/k"`�
MAIL
ADDRESS USE ZONE OCCUPANCY MAP
— -- -. - -- —-- ---- —__� BK e-PG
CITY TEL.NO. r.,..... .
CONTRACTOR ' 1
ADDRESS
--- -- --- -- — JOB N0.
CITY TEL.NO. TRUNK PERMIT NO. -
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REGISTRATION N STATE
ROAD PERMIT NO. � -+
LEGAL
DESCRIPTION OT No. STATE ENCROACH ENT
— --- — --- - PERMIT NO.
BLOCK fR TRACT INDUSTRIAL
---- 'WASTE APPROVAL
SIZE OF LOT N0.OF BLDGS. ..
--NOW ON LOT CJtARGES
USE OF _--
BUILDINGS CONNECTION FkARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT F
PUBLIC @ S 3.50 RECEIPT AW: ATE BY
HOUSE SEWER CONNECTI-NG--T6--
PRIVATE
GTOPRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG_OR EXCEPTION REC`&kDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING - j NO• DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00 I
6IS6014kifff AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 2.00 STATION/5-)o O ` / DEPTH /:
CESSP00 L—DRY W ELL ,!
SPECIAL CONDITIONS ONLY 2.00per• MANHHOLLEE REFERENCE /V!%
% LOWER
TYPE OF CONNECTION LENGT9 FRO f
OWNERS PERMIT ; 1 00 Y. M.L.TO P.L.
AUTHORIZATION TOTAL FEE
1
HAVE THIS DATE CONTRACTED W1TH THE HERE1 NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER _
SIGNED THIS.-------- __-----DAY OF_ '.. .___. .._.19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT-.__.....__--..._--__-__............:...:...,._.-_:.------__.._._.....e.__ BUILDING OR WORK
ADDRESS, _.__ SEPTIC TANK,SEEP,PIT(S)
-- __e:. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE y SEFF.PIT(S)E] CESSPOOLS[]
OF PERMITTEE._-
7GA642D 663 1/53